Webster Jayne, Hill Jenny, Lines Jo, Hanson Kara
TARGETS Consortium, Disease Control and Vector Biology, London, UK.
Health Policy Plan. 2007 Sep;22(5):277-93. doi: 10.1093/heapol/czm021. Epub 2007 Jun 28.
Coverage of insecticide-treated nets (ITNs) in sub-Saharan Africa is still low despite their proven efficacy, effectiveness and cost-effectiveness. Delivery systems for ITNs have been hotly debated, but there has been no structured approach to assessing their relative effectiveness. This paper aims to: propose a categorization of ITN and mosquito net delivery systems; classify existing systems according to this categorization; critique coverage measures reported; synthesize evidence about the levels of coverage achieved by each system; and identify current analytical gaps and future priorities.
We undertook a systematic review of published papers complemented by grey literature from projects and programmes. A 4-by-3 matrix was developed of delivery sector and cost to end user. Delivery systems were placed in the matrix based on project descriptions. Coverage and equity of coverage outcomes of the identified delivery systems were assessed for consistency with standard Roll Back Malaria (RBM) coverage indicators. These were placed in the matrix for comparison of outcomes by ITN delivery category.
Only 17 references with coverage data were identified, and amongst these there was variation from the RBM indicators. We identified three sets of coverage data where delivery and surveys to assess coverage of target groups were at national scale: public-free delivery in Togo; mixed-partially subsidized delivery in Malawi, and private-unsubsidized delivery in The Gambia. The highest level of household ownership was achieved through public-free delivery (62.5%), whilst use by pregnant women and by children under 5 was highest through private-unsubsidized delivery (67.2 and 67.7%, respectively).
There are no comparative studies of delivery systems for ITNs from which definitive evidence can be drawn, so conclusions on the relative merits of different delivery systems and levels of subsidy cannot be made. Development of methods of attributing household-level outcomes to specific delivery systems would aid in providing this evidence base. As countries scale-up efforts to deliver ITNs, our matrix provides an analytical tool for developing a comprehensive mapping of systems and outcomes. To guide strategic decision-making, cross-country and cross-regional comparisons of the outcomes of systems are needed to facilitate an analysis of the influence of contextual factors.
尽管经杀虫剂处理的蚊帐（ITN）已被证明具有功效、有效性和成本效益，但撒哈拉以南非洲地区的蚊帐覆盖率仍然很低。蚊帐的分发系统一直是激烈争论的焦点，但尚未有结构化的方法来评估它们的相对有效性。本文旨在：提出ITN和蚊帐分发系统的分类；根据此分类对现有系统进行分类；对所报告的覆盖率测量方法进行批判；综合关于每个系统所实现的覆盖率水平的证据；并确定当前的分析差距和未来的优先事项。
我们对已发表的论文进行了系统综述，并辅以来自项目和计划的灰色文献。构建了一个关于分发部门和终端用户成本的4×3矩阵。根据项目描述将分发系统置于该矩阵中。评估已确定的分发系统的覆盖率及覆盖率结果的公平性，以使其与标准的减少疟疾（RBM）覆盖率指标保持一致。将这些结果置于矩阵中，以便按ITN分发类别比较结果。
仅识别出17篇带有覆盖率数据的参考文献，并且其中存在与RBM指标的差异。我们确定了三组覆盖率数据，其中在全国范围内进行了分发以及对目标群体的覆盖率调查：多哥的免费公共分发；马拉维的混合部分补贴分发；以及冈比亚的私人非补贴分发。通过免费公共分发实现了最高水平的家庭拥有率（62.5%），而孕妇和5岁以下儿童的使用率通过私人非补贴分发最高（分别为67.2%和67.7%）。
尚无关于ITN分发系统的比较研究能得出确凿证据，因此无法就不同分发系统的相对优点和补贴水平得出结论。开发将家庭层面结果归因于特定分发系统的方法将有助于提供这一证据基础。随着各国加大提供ITN的力度，我们的矩阵提供了一种分析工具，用于全面绘制系统和结果。为指导战略决策，需要对系统结果进行跨国和跨区域比较，以促进对背景因素影响的分析。
